The aim of this study was to evaluate the cost-effectiveness of second-eye cataract surgery for older women with minimal visual dysfunction in the eye to be operated on from a Health and Personal Social Services perspective, compared to waiting list controls who had already undergone first-eye cataract surgery. A cost-utility analysis was undertaken alongside a randomized controlled trial of second-eye cataract surgery in secondary care ophthalmology clinics. A total of 239 women over 70 years old with one unoperated cataract were randomized to cataract surgery (expedited, approximately 4 weeks) or control (routine surgery, 12 months wait). Outcomes were measured in terms of quality-adjusted life years (QALYs), with health-related quality of life estimated using the EuroQol EQ-5D. The operated group had costs which were, on average, £646 more than the control group (95% confidence interval, £16–1276, P<0.04) and had a mean QALY gain of 0.015 (95% confidence interval, −0.039 to 0.068, P=0.59) per patient over 1 year. Therefore, the incremental cost-utility ratio was £44 263 over the 1-year trial period. In an analysis modelling costs and benefits over patients’ expected lifetime, the incremental cost per QALY was £17 299, under conservative assumptions. Second-eye cataract surgery is not likely to be cost-effective in the short term for those with mild visual dysfunction pre-operation. In the long term, second-eye cataract surgery appears to be cost-effective unless carer costs are included.

Before the Court of Appeal Over three weeks in June 2005, the Court of Appeal in London heard four appeals against convictions for non-accidental injury of infants: one murder, two manslaughter, and one grievous bodily harm. The three appeal judges delivered their judgement in a 67 page document on 21 July.1 Two appeals were upheld on the grounds of process, not medical evidence, one was dismissed, and in the fourth the conviction was reduced from murder to manslaughter. The basis of the appeals was that since these convictions in the 1990s and 2000, new research had suggested that the long held belief that infants who presented with encephalopathy, thin subdural haemorrhages, and retinal haemorrhages—the triad indicating “shaken baby syndrome”—had been subjected to extreme and repeated violence was wrong and that little or no trauma need be involved. The research in question has become variously known since its publication in 2003 as the “Geddes hypothesis” or the “unified hypothesis”.2 It was based on a pathological study of the dura of 50 intra-uterine, neonatal, or infant deaths, which identified microscopic haemorrhage within the layers of the dura in 36. This led to the speculation that subdural and retinal haemorrhage was not caused by traumatic shearing of subdural veins and retinal vessels but by a combination of cerebral hypoxia, raised intra-cranial pressure from brain swelling, raised arterial pressure, and raised central venous pressure. The publication of this research was met with considerable scepticism by most working in the field of paediatrics, paediatric pathology, and paediatric head injury,3–7 but it was enthusiastically embraced by a few8, …

The conventional patching/occlusion treatment for amblyopia sometimes gives disappointing results for a number of reasons: it is unpopular, prolonged, frequently resulting in poor or noncompliance, and also disrupts fusion. The aim of this research was to develop a novel virtual-reality (VR)-based display system that facilitates the treatment of amblyopia with both eyes stimulated simultaneously. We have adopted a multidisciplinary approach, combining VR expertise with a team of ophthalmologists and orthoptists to develop the Interactive Binocular Treatment (I-BiT™) system. This system incorporates adapted VR technology and specially written software providing interactive 2D and 3D games and videos to the patient via a stereo (binocular) display, and a control screen for the clinician. We developed a prototype research system designed for treatment of amblyopia in children. The result is a novel way to treat amblyopia, which allows binocular treatment. It is interactive, and as it is partially software based, can be adapted to suit the age/ability, and needs of the patient. This means that the treatment can be made captivating and enjoyable. Further research is on-going to determine the efficacy of this new modality in the treatment of amblyopia.

Background We have developed a novel application of adapted virtual reality (VR) technology, for the binocular treatment of amblyopia. We describe the use of the system in six children.Methods Subjects consisted of three conventional treatment 'failures' and three conventional treatment 'refusers', with a mean age of 6.25 years ( 5.42 - 7.75 years). Treatment consisted of watching video clips and playing interactive games with specifically designed software to allow streamed binocular image presentation.Results Initial vision in the amblyopic eye ranged from 6/12 to 6/120 and post-treatment 6/7.5 to 6/24-1. Total treatment time was a mean of 4.4 h. Five out of six children have shown an improvement in their vision ( average increase of 10 letters), including those who had previously failed to comply with conventional occlusion.Conclusions Improvements in vision were demonstrable within a short period of time, in some children after 1 h of treatment. This system is an exciting and promising application of VR technology as a new treatment for amblyopia.

Editor—We were interested to read Gomez-Arnau and colleagues’ article on anaesthesia-related diplopia after cataract surgery,1Gomez-Arnau JI Yanguela J Gonzalez A et al.Anaesthesia-related diplopia after cataract surgery.Br J Anaesth. 2003; 90: 189-193Crossref PubMed Scopus (75) Google Scholar and the correspondence by Lanigan and Hammond.2Lanigan LP Hammond CJ Anaesthesia-related diplopia after cataract surgery.Br J Anaesth. 2003; 91: 152-153Crossref PubMed Scopus (5) Google Scholar Transient diplopia (and very occasionally persistent diplopia) is a recognized postoperative complication of local anaesthetic cataract surgery. The exact aetiology of muscle injury is unknown but could be attributable to direct muscle or nerve trauma, local anaesthetic myotoxicity, periocular haemorrhage, or a combination of these.3Pearce IA McCready PM Watson MP et al.Vertical diplopia following local anaesthetic cataract surgery: predominantly a left eye problem?.Eye. 2000; 14: 180-184Crossref PubMed Scopus (22) Google Scholar In our department, ≈2800 local anaesthetic cataract operations are performed each year under retrobulbar, peribulbar, sub-Tenons’ or topical local anaesthesia. These are done with or without hyaluronidase and are administered by junior and senior members of the surgical and anaesthetic teams. From our experience over 10 years, not one case of persistent postoperative diplopia has been seen. It is true to say that the non-occurrence of an adverse event in a surgical series does not mean it cannot happen.4Eypasch E Lefering R Kum CK et al.Probability of adverse events that have not yet occurred: a statistical reminder.Br Med J. 1995; 311: 619-620Crossref PubMed Scopus (256) Google Scholar The probability of such adverse events during and after operations that have not yet occurred in a finite number of patients (n) can be estimated with Hanley’s simple formula. It states that if none of n patients showed the event with which one is concerned, one can be 95% confident that the chance of this event is, at most, 3 in n (i.e. 3/n). In other words, the upper 95% confidence limit of a 0/n rate is ≈3/n (for n>30).5Hanley JA Lippman-Hand A If nothing goes wrong, is everything alright?.JAMA. 1983; 259: 1743-1745Crossref Scopus (1080) Google Scholar Therefore, the maximum risk of this complication in our patients would be 3/2800 (0.001%). It seems, therefore, that the incidence of 0.25% reported by Gomez-Arnau and colleagues,1Gomez-Arnau JI Yanguela J Gonzalez A et al.Anaesthesia-related diplopia after cataract surgery.Br J Anaesth. 2003; 90: 189-193Crossref PubMed Scopus (75) Google Scholar and 0.64% reported by Lanigan and Hammond6NG Strouthidis, S Sobha, LP Lanigan, Vertical diplopia following peribulbar anaesthesia: the role of hyaluronidase, J Paediatr Ophthalmol Strabismus,; in pressGoogle Scholar is unusually high, and not what would be expected after statistical analysis.

A retrospective review was carried out of patients under 16 years old with malignant hypertension, who had been referred to a teaching hospital ophthalmology department because of reduced visual acuity. Four patients (three girls, one boy) were seen between 1994 and 2000 with a mean age at presentation of 11.5 years (range 9-15). In the short term, visual acuity improved after control of blood pressure in all four patients. However, in the long term, two patients were registered blind one to two years after presentation, one because of a choroidal neovascular membrane developing at the macula, and the other because of progressive optic neuropathy. Both of these patients had a longer duration of symptoms before diagnosis, worse visual acuity, and higher blood pressure at presentation when compared with the patients who made a good visual recovery. These observations suggest that early diagnosis of malignant hypertension in children is essential in reducing the likelihood of permanent severe visual damage.